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    v1.0.31
    OpenPayerPolicy UpdatesClinical/Medical PolicyWellcare Hawaii External Ocular Coverage | OpenPay…
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    CurrentWellcare HawaiiPolicy CP.VP.43

    External Ocular Photography

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    This policy governs the medical necessity and coding of external ocular photography used to document and track progression of external eye, eyelid, ocular adnexal, and selected anterior-segment conditions. It applies to providers and health plans affiliated with Centene Corporation, including Wellcare Hawaii.

    Policy Summary
    PayerWellcare Hawaii
    PolicyExternal Ocular Photography
    Policy CodePolicy N/A
    Change TypeAdministrative/template revisioncontraindications added
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument the relevant external ocular condition and use the photographs to track its medical progress.
    SourceLink
    POLICY UPDATE CHANGES

    The policy was converted to a new template and contraindications were added.

    92285Covered external ocular photography procedure
    6Clinical condition categories identified as medically necessary
    3Explicit situations deemed not medically necessary
    ICD-10-CMDiagnosis code set supporting coverage criteria

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Medical Necessity Criteria

    Medically Necessary External Ocular Photography

    External ocular photography is medically necessary to track progression when the patient has one or more of the following qualifying conditions:

    Qualifying condition: Keratitis, corneal degeneration, dystrophy, injury, edema, ulceration, opacification, ectasia, or perforation; iridocyclitis or associated glaucoma; anterior chamber inflammation, hyphema, narrow angle, or synechiae; conjunctivitis, episcleritis, or scleritis; eyelid pathology including blepharitis, dermatitis, entropion, extropion, ptosis, retraction, xanthelasma, chloasma, madarosis, edema, or vascular abnormalities; or external ocular or eyelid pathology including neoplasms, melanomas, carcinomas, cysts, trauma, or burns.

    The photographs must be used to track progression of the qualifying condition.

    Routine use of external ocular photography solely to document the appearance of healthy anatomy is not medically necessary.

    External ocular photography is not medically necessary when it provides duplicative documentation of retinal pathology already obtained through anterior segment scanning computerized ophthalmic diagnostic imaging, unless the additional procedure provides new information that assists clinical decision-making.

    Repeated external ocular photography is not medically necessary when the disease is controlled and/or stable.

    External ocular photography is not medically necessary for routine documentation of healthy anatomy, duplicative documentation without new clinical information, or repeated imaging of controlled and/or stable disease.

    Procedure and Diagnosis Codes

    CPT CodeCPTCovered
    92285External ocular photography with interpretation and report for documentation of medical progress (eg, close-up photography, slit lamp photography, goniophotography, stereo-photography)
    ICD-10-CM Diagnosis Codes that Support Coverage CriteriaICD-10Covered
    No codes listed
    ICD-10 Diagnosis CodesICD-10
    No codes listed
    Covered ICD-10-CM diagnosis codesICD-10Covered
    H21.301Idiopathic cysts of iris, ciliary body or anterior chamber, right eye
    H21.302Idiopathic cysts of iris, ciliary body or anterior chamber, left eye
    H21.303Idiopathic cysts of iris, ciliary body or anterior chamber, bilateral
    H21.311Exudative cysts of iris or anterior chamber, right eye
    H21.312Exudative cysts of iris or anterior chamber, left eye
    H21.313Exudative cysts of iris or anterior chamber, bilateral
    H21.321Implantation cysts of iris, ciliary body or anterior chamber, right eye
    H21.322Implantation cysts of iris, ciliary body or anterior chamber, left eye
    H21.323Implantation cysts of iris, ciliary body or anterior chamber, bilateral
    H21.341Primary cyst of pars plana, right eye
    1–10 of 21
    1/3
    Covered ICD-10-CM diagnosis codesICD-10Covered
    H21.521Goniosynechiae, right eye
    H21.522Goniosynechiae, left eye
    H21.523Goniosynechiae, bilateral
    H21.531Iridodialysis, right eye
    H21.532Iridodialysis, left eye
    H21.533Iridodialysis, bilateral
    H21.541Posterior synechiae (iris), right eye
    H21.542Posterior synechiae (iris), left eye
    H21.543Posterior synechiae (iris), bilateral
    H21.551Recession of chamber angle, right eye
    1–10 of 18
    1/2
    Covered ICD-10-CM diagnosis codesICD-10Covered
    H40.1431Capsular glaucoma with pseudoexfoliation of lens, bilateral, mild stage
    H40.1432Capsular glaucoma with pseudoexfoliation of lens, bilateral, moderate stage
    H40.1433Capsular glaucoma with pseudoexfoliation of lens, bilateral, severe stage
    H40.51X1Glaucoma secondary to other eye disorders, right eye, mild stage
    H40.51X2Glaucoma secondary to other eye disorders, right eye, moderate stage
    H40.51X3Glaucoma secondary to other eye disorders, right eye, severe stage
    H40.52X1Glaucoma secondary to other eye disorders, left eye, mild stage
    H40.52X2Glaucoma secondary to other eye disorders, left eye, moderate stage
    H40.52X3Glaucoma secondary to other eye disorders, left eye, severe stage
    H40.53.X1Glaucoma secondary to other eye disorders, bilateral, mild stage
    1–10 of 24
    1/3
    Covered ICD-10-CM diagnosis codesICD-10Covered
    S01.121ALaceration with foreign body of right eyelid and periocular area, initial encounter
    S01.121DLaceration with foreign body of right eyelid and periocular area, subsequent encounter
    S01.121SLaceration with foreign body of right eyelid and periocular area, sequela
    S01.122ALaceration with foreign body of left eyelid and periocular area, initial encounter
    S01.122DLaceration with foreign body of left eyelid and periocular area, subsequent encounter
    S01.122SLaceration with foreign body of left eyelid and periocular area, sequela
    S01.131APuncture wound without foreign body of right eyelid and periocular area, initial encounter
    S01.131DPuncture wound without foreign body of right eyelid and periocular area, subsequent encounter
    S01.131SPuncture wound without foreign body of right eyelid and periocular area, sequela
    Covered ICD-10-CM diagnosis codesICD-10Covered
    S01.132APuncture wound without foreign body of left eyelid and periocular area, initial encounter
    S01.132DPuncture wound without foreign body of left eyelid and periocular area, subsequent encounter
    S01.132SPuncture wound without foreign body of left eyelid and periocular area, sequela
    S01.141APuncture wound with foreign body of right eyelid and periocular area, initial encounter
    S01.141DPuncture wound with foreign body of right eyelid and periocular area, subsequent encounter
    S01.141SPuncture wound with foreign body of right eyelid and periocular area, sequela
    S01.142APuncture wound with foreign body of left eyelid and periocular area, initial encounter
    S01.142DPuncture wound with foreign body of left eyelid and periocular area, subsequent encounter
    S01.142SPuncture wound with foreign body of left eyelid and periocular area, sequela
    S01.151AOpen bite of right eyelid and periocular area, initial encounter
    1–10 of 21
    1/3
    Covered ICD-10-CM diagnosis codesICD-10Covered
    S02.32XAFracture of orbital floor, left side, initial encounter for closed fracture
    S02.32XBFracture of orbital floor, left side, initial encounter for open fracture
    S02.32XDFracture of orbital floor, left side, subsequent encounter for fracture with routine healing
    S02.32XGFracture of orbital floor, left side, subsequent encounter for fracture with delayed healing
    S02.32XKFracture of orbital floor, left side, subsequent encounter for fracture with nonunion
    S02.32XSFracture of orbital floor, left side, sequela
    S05.21XAOcular laceration and rupture with prolapse or loss of intraocular tissue, right eye
    S05.21XDOcular laceration and rupture with prolapse or loss of intraocular tissue, right eye, subsequent encounter
    S05.21XSOcular laceration and rupture with prolapse or loss of intraocular tissue, right eye, sequela
    Covered ICD-10-CM diagnosis codesICD-10Covered
    S05.22XAOcular laceration and rupture with prolapse or loss of intraocular tissue, left eye, initial encounter
    S05.22XDOcular laceration and rupture with prolapse or loss of intraocular tissue, left eye, subsequent encounter
    S05.22XSOcular laceration and rupture with prolapse or loss of intraocular tissue, left eye, sequela
    S05.31XAOcular laceration without prolapse or loss of intraocular tissue, right eye, initial encounter
    S05.31XDOcular laceration without prolapse or loss of intraocular tissue, right eye, subsequent encounter
    S05.31XSOcular laceration without prolapse or loss of intraocular tissue, right eye, sequela
    S05.32XAOcular laceration without prolapse or loss of intraocular tissue, left eye, initial encounter
    S05.32XDOcular laceration without prolapse or loss of intraocular tissue, left eye, subsequent encounter
    S05.32XSOcular laceration without prolapse or loss of intraocular tissue, left eye, sequela
    S05.41XAPenetrating wound of orbit with or without foreign body, right eye, initial encounter
    1–10 of 21
    1/3
    Covered ICD-10-CM diagnosis codesICD-10Covered
    S05.61XAPenetrating wound without foreign body of right eyeball, initial encounter
    S05.61XDPenetrating wound without foreign body of right eyeball, subsequent encounter
    S05.61XSPenetrating wound without foreign body of right eyeball, sequela
    S05.62XAPenetrating wound without foreign body of left eyeball, initial encounter
    S05.62XDPenetrating wound without foreign body of left eyeball, subsequent encounter
    Covered ICD-10-CM diagnosis codesICD-10Covered
    S05.62XSPenetrating wound without foreign body of left eyeball, sequela
    S05.71XAAvulsion of right eye, initial encounter
    S05.71XDAvulsion of right eye, subsequent encounter
    S05.71XSAvulsion of right eye, sequela
    S05.72XAAvulsion of left eye, initial encounter
    S05.72XDAvulsion of left eye, subsequent encounter
    S05.72XSAvulsion of left eye, sequela
    T26.01XABurn of right eyelid and periocular area, initial encounter
    T26.01XDBurn of right eyelid and periocular area, subsequent encounter
    T26.01XSBurn of right eyelid and periocular area, sequela
    1–10 of 23
    1/3
    Covered ICD-10-CM diagnosis codesICD-10Covered
    T26.22XDBurn with resulting rupture and destruction of left eyeball, subsequent encounter
    T26.22XSBurn with resulting rupture and destruction of left eyeball, sequela
    T26.51XACorrosion of right eyelid and periocular area, initial encounter
    T26.51XDCorrosion of right eyelid and periocular area, subsequent encounter
    T26.51XSCorrosion of right eyelid and periocular area, sequela
    T26.52XACorrosion of left eyelid and periocular area, initial encounter
    T26.52XDCorrosion of left eyelid and periocular area, subsequent encounter
    T26.52XSCorrosion of left eyelid and periocular area, sequela
    T26.61XACorrosion of cornea and conjunctival sac, right eye, initial encounter
    T26.61XDCorrosion of cornea and conjunctival sac, right eye, subsequent encounter
    1–10 of 14
    1/2
    Covered ICD-10-CM diagnosis codesICD-10Covered
    T26.71XACorrosion with resulting rupture and destruction of right eyeball, initial encounter
    T26.71XDCorrosion with resulting rupture and destruction of right eyeball, subsequent encounter
    T26.71XSCorrosion with resulting rupture and destruction of right eyeball, sequela
    T26.72XACorrosion with resulting rupture and destruction of left eyeball, initial encounter
    T26.72XDCorrosion with resulting rupture and destruction of left eyeball, subsequent encounter
    T26.72XSCorrosion with resulting rupture and destruction of left eyeball, sequela
    T26.81XACorrosions of other specified parts of right eye and adnexa, initial encounter
    T26.81XDCorrosions of other specified parts of right eye and adnexa, subsequent encounter
    T26.81XSCorrosions of other specified parts of right eye and adnexa, sequela
    T26.82XACorrosions of other specified parts of left eye and adnexa, initial encounter
    1–10 of 12
    1/2

    Documentation and Use Requirements

    Documentation Required

    Document Medical Progress

    Document the relevant external ocular or anterior-segment condition and use external ocular photography to track medical progress. CPT 92285 is external ocular photography with interpretation and report for documentation of medical progress; include the interpretation and report with the submitted documentation.

    • Applicable conditions include corneal disease or injury, iridocyclitis or associated glaucoma, anterior chamber inflammation or related pathology, conjunctivitis, episcleritis, scleritis, eyelid pathology, and external ocular or eyelid neoplasms, trauma, or burns.
    Denial Risk

    Healthy Anatomy Only

    Do not use external ocular photography routinely when the sole purpose is to document the appearance of healthy anatomy.

    • Routine photography of healthy anatomy is not medically necessary and presents a denial risk.

    Clinical Background

    External ocular photography is a non-invasive method of documenting the external structures of the eye, including the eyelids, lashes, sclera, conjunctiva, and cornea. It may also capture selected anterior-segment structures, such as the anterior chamber, iris, crystalline lens, and filtration angle. Images may be obtained with a hand-held camera, slit-lamp-integrated camera, goniophotography lens, or close-up stereo camera and stored as prints, slides, video, or digital files.

    Key Definition

    External Ocular Photography
    ScopeDocuments the external eye, eyelids, and ocular adnexa, including the eyelids, lashes, sclera, conjunctiva, and cornea.
    Anterior-segment structuresMay also document the anterior chamber, iris, crystalline lens, and filtration angle.
    Clinical useUsed to photo-document conditions and track medical progress; photographs can record the eye and its motion more accurately than physician chart notes or drawings.
    Photography methodsMay use a close-up hand-held camera, slit-lamp-integrated camera, goniophotography lens, or close-up stereo camera.
    Image formatsPhotographs may be stored as prints, slides, videotapes, or digital files; the code does not differentiate between film and digital media or between still and video images.
    Policy Summary
    PayerWellcare Hawaii
    PolicyExternal Ocular Photography
    Policy CodePolicy N/A
    Change TypeAdministrative/template revisioncontraindications added
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument the relevant external ocular condition and use the photographs to track its medical progress.
    SourceLink
    On This Page
    Medical Necessity CriteriaProcedure and Diagnosis CodesDocumentation and Use RequirementsClinical BackgroundKey Definition
    Denial Risk

    Duplicative Diagnostic Documentation

    Avoid duplicative documentation of retinal pathology with anterior segment scanning computerized ophthalmic diagnostic imaging. The additional diagnostic procedure is not medically necessary unless it provides new information that assists in clinical decision-making.

    • Document the distinct clinical information and decision-making value when both procedures are performed.
    Denial Risk

    Repeat Imaging for Stable Disease

    Repeated external ocular photography is not medically necessary in the presence of controlled and/or stable disease.

    • Repeat imaging should be supported by a documented change in condition or a continuing need to assess progression.
    Documentation Required

    Qualifying Condition and Purpose Required

    Before performing or billing external ocular photography, identify a qualifying external ocular or anterior-segment condition and document that the photographs are needed to track medical progress. Photography without both an identified condition and a progression-tracking purpose does not meet the policy’s medical-necessity requirement.

    • Link the service to the documented condition and explain how the images will inform assessment of medical progress or clinical decision-making.
    • CPT 92285 is intended for external ocular photography with interpretation and report for documentation of medical progress.